Archive for February, 2010

He Forgets His Medication

pathways February 17th, 2010

       Schizophrenia is a chronic illness that affects nearly every aspect the client. Treatment planning should focus on reducing or eliminating symptoms; maximize the quality of life and adaptive functioning; and advance and retain recovery as much as possible. The implications of an inaccurate diagnosis are potentially enormous. Thus, it is very important that the diagnosis be a process, and not the one-time result of a fixed moment in time. The treatment plan must be looked at as a work in progress especially as the diagnosis is reevaluated or because of new information becoming available concerning the symptoms, or the client.

The case study “He forgets to take his medication”, a 45-year old male with chronic schizophrenia who continually relapses after two weeks or so due to forgetting to take his prescriptions. The client does keep his appointments. Although the medications do alleviate his symptoms, he is non compliant to his prescription therapy. Therefore his psychiatrist adjusts the therapy to biweekly injections.

According to Butcher, Mineka and Hooley (2007) “anti psychotic medications are usually administered by mouth. However some patients, particularly those with chronic schizophrenia, are often not able to remember to take their medications each day” (pp. 609-610). Therefore in treatment planning the clinician is wise to identify barriers that may prevent the client’s ability to carry through with the directions of the therapy. For example if the client is severely cognitively impaired or disorganized or less than optimal environmental circumstances.

My choice of therapeutic approach is multifaceted for this client. First, I would recommend performing a medical and mental evaluation and history of these including a mental status examination, neurological, and laboratory examinations with vitals such as heart rate, blood pressure and temperature. I would also recommend a toxicology screening. If possible, and if the client gives permission, interviews with family or associates could be conducted especially if the client’s accounts are unreliable. Because he has been unsuccessful at self administering his medication, the reason for this should be assessed and included in the treatment plans. As soon as possible, so long as diagnosis is not interfered with, pharmacological treatments should be administered because of the risks associated with the symptoms of schizophrenia such as emotional trauma, the stress and disruption of the client’s life, and the possibility for self-harm.

Butcher et al. (2007) have stated: “Not all prospective clients, regardless of their need for treatment, are ready for the temporary discomfort that effective therapy might entail. In particular, a client with chronic schizophrenia and who is recently off medication or only taking it intermittently, may be too unstable for traditional psychotherapy because facing past experiences or simply to undergo any additional emotional pain could traumatize the client further. An integrated treatment program for this client will combine medications with a range of psychosocial services, social skills activities, community-based care, and possibly cognitive behavior oriented and eclectic therapy. Several factors to consider include the possibility for substance abuse, depression, and aggressive behavior. Craighead, (as cited by Butcher, et al., 2007) states Beck’s cognitive treatment therapies are highly documented to be efficacious for long-term alleviation of symptoms and relapse which for this particular case study could be promising. Cognitive behavior may help him cope with and process stresses so that full blown feelings of anxiety or panic may be averted.

In addition to educating clients and their families about schizophrenia, and dispelling unhelpful attitudes, cognitive behavior therapy could uncover false beliefs. In this regard, educating the client about the importance of participating in treatment, including medication and the relationship to stated personal goals might be able to be achieved because the client could see how behavior, cognition and emotions are directly impacted by medication. Awareness of the relationship between the consequences of schizophrenia and how it interferes with normal functioning will build connections that may improve the life experience of the schizophrenic client.
Finally, I think that treatment should involve highly structured behavior techniques and skills building, because these may positively influence the client’s increased chances of stabilization.

References:
American Psychiatric Association. (2000). DSM-IV-TR. Arlington, VA: Author.

Butcher, J. N., Hooley, J. M., & Mineka, S. (2007). Abnormal psychology (13th ed.). Boston: Pearson Education.

Values and Career

pathways February 14th, 2010

Theories of career counseling have been developed to help counselors apply their understanding of various behaviors in order to efficaciously and efficiently guide clients with career development and choices. Capuzzi & Stauffer (2006) stated “Before being able to effectively and efficiently provide career services appropriate to our times, the counselor must understand well established and emerging career theories, [and] their strengths and weaknesses… for diverse populations and a rapidly changing vocational terrain” (p.40).
According to Capuzzi & Stauffer (2006) the various theories of career counseling can be classified into several categories: Trait and factor theories; Developmental theories; Cognitive learning theories and approaches; Psychodynamic theories, and several more including some not so well known such as value based theory and chance/accident theory. Theories simplify complex human behavior and are therefore helpful as tools, which help us to understand ourselves and our clients. Krumboltz (as cited by Capuzzi & Stauffer, 2007) stated that the theory provides a simplified framework of the behavior it attempts to describe and illuminate much like a map describes a territory we may want to study or travel (p.41). The only thing I might add to this is something I have been saying now for some time and that is: “Do not ever confuse the map for the territory”. In other words, what is real is the experience not the representation and we should never fit the evidence to the map.

Most of the theories describe different ways of considering individual traits for the purpose of appropriately matching career paths with personalities, and satisfaction depending on the viewpoint of the theory. The task at hand is to find the theory that most suits the ideologies and make-up of the individual in order to find career paths that are lasting and fulfilling.

The theory that rings true for me is “Values-based career counseling”. I strongly believe that when one’s values are not in sync with one’s behavior that over time this will lead to dissatisfaction and poor performance. It is my belief that when values are not in sync with beliefs that this sets up a situation of dissatisfaction and I think a host of other dysfunctional behaviors which are not efficacious to career or life satisfaction. Values need to be backed-up by behavior or the individual will not be happy for long for: until “the structure of an individual’s values matches the value structure of the work environment” (p.48) the conflict will not allow for success. I think that when values, beliefs and behavior are not aligned and prioritized, people (workers) are not happy.

People in recovery, and who may be seeking new careers, may find that the source of their dissatisfaction in their lives is due to his or her values not being aligned with his or her behavior. This conflict can set up defensive behaviors as the person tries to escape the conflict and discomfort of not being authentic. A person’s true values could be buried under society’s expectations of that person and he or she may have lost touch with what is important. Rediscovering one’s values and shaping behavior that expresses a deeper truth may be more rewarding and therefore set up a lifetime of personal reform.

Career Counseling

pathways February 14th, 2010

Clients in mental health and private practice settings have unique issues and the services they receive are only as good as the counselor’s skills. It is suggested that career counseling for individuals with mental health issues requires a counselor who is skilled in both mental health and career counseling. Herr, 1992 (as cited in Capuzzi & Stauffer, 2006) suggested that unless one is willing to look at the interaction of career counseling and behavior health or mental health problems, there is little likelihood that one can be effective in assisting persons with job adjustment problems, dislocated workers, spouses of those experiencing job dislocations, or recovering alcoholics (p. 283). The client who enters career counseling sometimes discovers that unresolved or current issues may surface as a result of confronting perceived stressors, such as severe mental disorders, depression, anxiety and phobias.

These clients have several needs, as do most, however, the concerns are certainly magnified by the additional diagnosis. Aside from mental health, and factors related to career planning, this counselor may benefit from a solid knowledge of the effects, side effects, adverse reactions and contraindicated substances in relation to the medications and treatments that must be addressed. Therefore the mental health professional who would counsel this population will probably need to blend or balance mental health counseling with career counseling just for starters. However, according to Capuzzi and Stauffer (2006) efficacy increases for this population as a result of counseling.

People with Severe Mental Disorders (SMD) have additional emotional hurdles to overcome or defuse like low self esteem, depression and apathy. Possibly this is due to years of repeated exposure to negative attitudes from others including his or her immediate support group. We have learned of the power of this in our coursework here at Walden and Sue & Sue (2008) have expressed that the experiences and expectations of others may determine how SMD clients view themselves.

Saunders, Peterson. Sampson, & Reardon (as cited by Capuzzi & Stauffer, 2006) have found research which indicates significant positive relationships between Major Depressive Disorder and career indecision, and between depression and dysfunctional career thought, and a significant negative relationship between depression and vocational identity (p.290). Another concern for these clients is that they can be apathetic or disengaged and unable to commit to a course of action, which sets up further stress because work is not being done, and depression, hopelessness increase. This client may benefit from the techniques of cognitive behavior therapy, and group work. The counselor will assist the client in creating and understanding his or her own realistic and authentic values, likes and dislikes. The counselor will challenge and teach the client how to stop irrational thoughts, as well as job search skills.

Symptoms of PTSD can affect understanding and memory, concentration, persistence, social interaction, and adaptation and can significantly reduce stress tolerance. Each of these issues will have a significant impact on the life experience of the client including those related to career. These clients have difficulty with stress, deadlines, change and independent goal setting (Capuzzi et al., 2006). Counselors seek to educate the client about the disorder and its effects mentally, emotionally and physically. Treatments may include congruence, self-exploration, cognitive-behavioral techniques such as journaling, and/or guided meditation. Primary support is also very influential and therefore group therapy could be empowering.

Delusional?

pathways February 14th, 2010

What I am wondering is what is the difference between delusions and beliefs? Beliefs are very powerful, and most people do not like when their beliefs are challenged or threatened. However, what makes a belief a truth? It can’t just be because we want it to be so. That is the definition of a self fulfilling prophesy. It is probably not a good idea to just decide something is true because we want it to be true. However, even though we do not think so, I ‘m sure we have all tried to do that.

For example I there was a case study in one of my core classes for my Master’s degree in Mental Health Counseling, that described a young man who chose not to study for his PSAT, because he believed that he would do well with the knowledge he had “as is”. Convenient, however, he did not do well on the test. Now is he deluded because he wanted something to be true, and then decided it was in fact true when it was not true?This makes me wonder what part, if any, does Ego play in this phenomenon?

Many religious beliefs are upheld as true no matter how much science, reality, or any contradictory concepts, may indicate that another truth could be present. Adherence to beliefs is linked to survival and this is why people often go into an uproar when their beliefs are challenged. It isn’t the beliefs themselves, that cause the uproar. When survival is at stake, an individual will defend and fight back to the end. People tend to believe that their beliefs give their lives meaning, purpose and even survival.

It seems to be a natural tendency to think that we are our thoughts and beliefs and to attach ourselves to these fleeting notions. However thoughts and beliefs change, while we, or “I”, the observer remains constant. In my own recovery, I have learned to ask myself : “who am I without my stuff, who am I without my house and car; who am I without my job, my friends, and the biggie, my children?”

Who really knows what is the truth and what is a delusion? Maybe it is just that when our delusions do not match-up with the mainstream’s, then we are considered delusional. Delusions that are considered bizarre could be difficult to weigh-out or judge especially since for every culture there exists different beliefs.

That being said, I do realize that delusions are the hallmark to the mental illness Schizophrenia, and I believe that treatment and education are a must. Individuals who suffer from this disease in its more serious forms who have disorganized thoughts, and behaviors, hallucinations and dysfunctions, do suffer greatly.

Many moons ago, when I was an undergraduate at McGill University in Montreal, I was fortunate to have been given the opportunity to assist in a study which was at the time attempting to differentiate between all the different types of schizophrenia. I remember being handed dozens of pages containing many proposed differentiated forms of schizophrenia. At the time the researcher was attempting to figure out whether these were all aspects of one disease or whether they are all different and unrelated –even though they shared many symptoms.

I graduated before the study was concluded but I remember that at the time we were beginning to suspect that they shared the same root but mutated enough, that the forms were actually different disorders. Human history is filled with delusional figures, religious and otherwise, revered and feared. It goes back a long way and I believe we all have the potential to be delusional.

Perhaps the ability to experience delusions is linked with the survival mechanism. It could be a way of psychically protecting the experiential world of the individual from perceived threat. This would actually be a compelling argument for an actual connection between emotions and biology.  The body’s, indeed Life’s “fight” to survive, is the primary emotion from which all others stem. Primary Emotion married Physical and gave birth to Love and Fear, followed by Separation and Unity. The expression of pure being(non physical) is perpetuated by the continuation of consciousness (physical).

Also I have noticed it seems as long as the delusion is collectively believed, then deluded or not it becomes what we refer to as normal.

The French term, folie a deux, translates something like: two, sharing a madness, and was coined in the 19th century in France. I may be going out on a limb here, but I am beginning to see some interesting relationships. I believe it was Carl Jung who theorized about a concept he called the collective unconscious, and Toltec philosophies theorize that we are all (people/consciousness) dreaming a dream, that life is but a dream. Further, in everyday circumstances collectivism is expressed in many forms. Republicans, and Dems; Christian and Jew, and on and on. The more people who join in a belief, whether delusional or not, the more powerfully it expresses itself.

Beliefs are as powerful, in my opinion as drives so the formation of delusions seems almost like a malfunctioning in belief formation. Think of cults. Also, the power of suggestion is incredibly mighty. When you consider these kinds of things, and the pull towards collectivism in general, this disorder seems conceptually to make a little more sense to me.

In a way, we are all buying into each others’ illusions and delusions but again the measurement that tips the scale is the bizarreness and length of time of the shared delusion.

Brief psychotic disorder comes on suddenly, as opposed to its cousin, shared psychotic disorder. Shared Psychotic Disorder seems to be more gradual in development and is related to being exposed to the other’s delusion over time.

Because of the suddenness of Brief Psychotic disorder I suspect that a chemical change, beyond regular metabolic changes and exchanges is the cause. This could be the consequence to experiencing extreme and unusual stress. Stress causes the brain to secrete powerful hormones and toxins and a sudden flood of these will no doubt be disorienting at best. Ruling out medical prescriptions, and illegal drugs, or head trauma, what else could be the cause?

Cognitive theories focus on the delusional beliefs which have a biological cause. Behavioral theory is also needed for Schizophrenia because another hallmark, aside from disorganized thought and speech, individuals display no regard for social skills or acceptable responses.

Friendship, Ghana Time -or- Honor the moment and make friends.

pathways February 13th, 2010

Beauty and love always happen at just the right time, and this was no exception. It happened on a plane, but it could have been anywhere, anytime. It was one of those light filled moments where the sacred intervenes and imposes unconditional witnessing and connection. It is a gift, and it is one of the best kinds. Experiencing unity like that is is a gift because the the only real worth of a human life can be measured by the depth and quality of one’s connections. I often meet people in  somewhat unusual places. I’ve never had a hard time talking with strangers and my radar has been my guide, and she has never let me down. Most recently, on a plane returning from my second residency in Dallas TX, I met a delightful woman from Ghana, just because I we sat next to each other and I started talking with her. We quickly realized how much fun it was talking to each other and the conversation just led from one truth to another forming a truer and truer bond all the way to our souls. On top of that, the woman’s name is “Gifty”. How right is that? I have been blessed in friendships and I am so honored that the universe has given me all the life experiences it has and will continue to give. So if you take anything from this know that joy is in witnessing, and there is no witnessing going on in lies, fear and addiction. Honor the moment and make friends.